Volume-outcome relationships for primary total elbow arthroplasty surgery in England: Analysis of the hospital episode statistics dataset

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Background: Total elbow arthroplasty (TEA) is a low-volume, high-complexity procedure and clinical guidelines recommend moving to a centralised network model. The aim of the study was to assess the effect of surgeon and unit volume on patient and service level clinical outcomes. Methods: Analysis the Hospital Episodes Statistics database (HES) for elective and emergency primary TEA surgery between January 2014 and December 2023 was performed. The exposures of interest were surgeon and trust volume in the 12 months preceding index surgery. The primary outcome was revision surgery within 12 months of index procedure. Secondary outcomes were 30-day emergency readmission and length of stay (LOS) greater than the median. Results: In total, 4101 primary TEA cases performed in 123 trusts were included. One-year revision and 30-day emergency readmission were not associated with trust or surgeon volume. LOS greater than the median showed a significant association with both surgeon and unit TEA volume. Patients undergoing primary TEA by surgeons performing fewer than 10 cases per year have three times the likelihood of LOS over three days. Conclusion: There are significant resource savings from networked service reconfiguration. Careful monitoring of clinical outcomes is required, ideally using patient reported outcomes in addition to implant survival, readmission and LOS.

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